Procysbi (cysteamine bitartrate) — Blue Cross Blue Shield of Oklahoma
members residing in Ohio with Fully Insured or HIM Shop (SG) plan requesting use supported by literature or compendia evidence
Initial criteria
- Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG)
- AND patient does NOT have any FDA labeled contraindications to the requested agent
- AND ONE of the following: (1) patient has another FDA labeled indication for the requested agent and route of administration OR (2) patient has an indication supported in compendia for the requested agent and route of administration OR (3) prescriber submitted TWO peer-reviewed medical journal articles supporting proposed use as generally safe and effective (acceptable: randomized, double blind, placebo controlled clinical trials; case studies not acceptable)
Approval duration
12 months